Managing lymphoedema Print E-mail
Written by Anne F Williams   

From March 2006, standard and made-to-measure specialist compression garments for arm and leg lymphoedema have been available on the UK Drug Tariff. These are based on German compression standards[1] and provide higher levels of compression than those garments commonly used in venous disease (Table 1)

Compression garments are central to the effective management of lymphoedema but are only one aspect of a comprehensive approach that includes skincare, exercises, specialised manual lymph drainage massage and compression bandaging.

This article will outline the causes of lymphoedema and identify those at risk of chronic swelling (Table 2). It will describe the components of lymphoedema management (Table 3) and discuss the role of compression garments, highlighting the need for skilled prescription and follow-up of patients.

Lymphoedema is a term used to describe chronic swelling that develops due to a failure of the lymphatic system to remove adequately fluid and proteins from the interstitial tissues. A case ascertainment study identified lymphoedema in over 1.33 per 1,000 population, with the condition affecting all age groups but predominating in those over 65 years[2]. A review by Morgan et al found that lymphoedema had a considerable impact on quality of life in terms of functional impairment, skin problems, pain, poor psychological adjustment and economic difficulties[3]. Chronic inflammatory processes and tissue fibro-sclerosis are inherent to lymphoedema and may lead to hyperkeratosis, papillomatosis and an increased risk of severe cellulitis.

 

Image
Table 1. German[1] and British Standard COmpression Class (expressed as mmHg).

 

Aetiology


Lymphoedema has a wide range of cancer and non-cancer-related causes and many patients also have concomitant conditions, such as cardiac or renal insufficiency, that further complicate the oedema. The term primary lymphoedema is commonly used to denote an intrinsic abnormality of the lymphatic system that may be genetic (Milroy’s disease) and can arise at birth or in the first two years. Meige’s disease is bilateral lower limb swelling from obliteration of distal lymphatics and occurs most commonly after puberty in women.

Secondary lymphoedema results from a variety of external factors that compromise lymphatic function. Examples include lymph node dissection in the management of breast cancer or malignant melanoma, radiotherapy, invasive malignancy, chronic skin problems, orthopaedic surgery and traumatic injury (Table 2).

Increased capillary filtration associated with advanced venous disease, chronic immobility or limb dependency, may also overwhelm the lymphatic system resulting in a chronic oedema (often referred to as lymphovenous oedema) that compromises skin condition and impairs ulcer healing.

Management


Conservative lymphoedema management strategies adopted from lymphology centres in Germany and Austria in the 1980s are widely accepted in the UK. Surgery or the use of intermittent compression pumps are now rarely indicated. Table 3 overviews the different lymphoedema patient groups and their management according to severity[4].
 

Image
Table 2. Possible risk factors for chronic oedema/lymphoedema.
Individualised assessment by an appropriately trained healthcare professional is paramount to ensuring a comprehensive treatment programme. Patients should also be reviewed at suitable intervals, particularly if compression hosiery is prescribed. Management may include: 

  • Meticulous skin and preventative care to reduce the risk of skin problems and cellulitis;  
  • Manual lymph drainage massage to enhance the removal of protein-rich fluid from the tissues, often through collateral lymph drainage routes;
  • Exercise and movement to enhance lymph drainage and maximise the skeletal muscle pump;
  • Compression bandaging (in the short-term) to reduce swelling, normalise limb shape and improve skin integrity;
  • Compression garments (in the long-term).

Compression garments


Compression garments are indicated to maintain limb shape and volume over the long-term. They exert their effect by:

  • Opposing capillary filtration and thereby reducing the formation of excess interstitial fluid;[5]
  • Increasing lymphatic re-absorption and lymph transport;[6]
  • Improving venous return and reducing venous reflux.[6]


Lymphoedema compression garments differ from other hosiery in several ways. The former are manufactured to higher compressions, similar to those identified in German compression standards[6]. They use specific knitting techniques to achieve a stiffer material that more effectively contains severe lymphoedema and the fibro-sclerotic changes that can occur in lymphatic disease. Additionally, while some lymphoedema garments are circular knitted (as a tube), others are flat-knitted with a seam, producing a garment that is less elastic and more readily accommodates limb shape distortion, being more likely to bridge skin creases.

Flat-knit garments may be indicated following a course of lymphoedema bandaging, where rebound swelling may occur. They are often appropriate for severe lymphoedema of the lower limb, particularly in a higher compression, but can be used effectively and comfortably in a lower compression for patients with advanced breast cancer, for example, where arm swelling is unstable. Circular knit garments tend to be more elastic, softer and may be aesthetically pleasing to the patient, but are mainly indicated for well-shaped limbs.

A number of factors should be considered when selecting a garment:

  • What is the cause of the swelling?
  • What other contributing factors are present?
  • What assessment, measurements and/or investigations are necessary?
  • Is the patient at risk of arterial insufficiency?
  • What is the shape of the limb and is a standard or made-to measure garment required?
  • Is a circular or flat-knit garment required?
  • How severe and extensive is the lymphoedema and is Decongestive Lymphatic Therapy required (Table 3)?
  • Can the patient be referred to a local lymphoedema or other appropriate practitioner?


Assessment of arterial status, including the calculation of Ankle Brachial Pressure Index (ABPI), should be undertaken before prescribing lymphoedema compression garments. However, this may be problematic in patients with gross swelling and tissue fibro-sclerosis. Patients with an ABPI of less than 0.8 will require further assessment to determine suitability for compression therapy.

Image
Table 3. Staging and Management of lymphoedema/chronic oedema. (Adapted from British Lymphology Society[4] and Doherty et al[10])

 

Drug treatments


Drugs have limited scope. Benzopyrones have been used in the past, particularly in the developing world, but there is little evidence to support or refute their use in lymphoedema[7]. Diuretics do not influence lymph function and are not recommended for routine use. However, they may benefit patients with concomitant problems such as cardiac failure. In the short term, spironolactone may be used in advanced cancer and ascites, although renal function should be monitored closely.

A consensus document[8] on the use of antibiotics for cellulitis in lymphoedema recommends oral amoxicillin 500mg eight-hourly, with the addition of flucloxacillin 500mg six-hourly if there is evidence of Staphylococcus aureus infection. Patients who are allergic to penicillin should be prescribed clindamycin 300mg six-hourly, also indicated if there is limited response after 48 hours to amoxicillin. Antibiotic prophylaxis with penicillin V 500mg daily (1g if weight is over 75kg) is recommended if a patient has two or more attacks of cellulitis per year.

Service issues


Evidence exists that lymphoedema is poorly recognised and often under resourced,[8] particularly in terms of non-cancer-related lymphoedema. Many areas do not have an established or comprehensive lymphoedema service. Current work by the Lymphoedema Framework Project, British Lymphology Society and the Lymphoedema Support Network is supporting the development and evaluation of lymphoedema services in the UK[9].

The advent of lymphoedema garments on to the UK Drug Tariff is one aspect of this work and provides greater scope for establishing primary care-based services for people with lymphoedema. However, this also raises issues in terms of the skill and knowledge base of those prescribing compression garments for people with lymphoedema.

Conclusion


Lymphoedema is a long-term, often complex condition requiring a comprehensive approach to treatment, including the fitting of specialist lymphoedema hosiery garments. Ideally all patients with lymphoedema should be assessed by a suitably qualified healthcare professional although there is now increased scope for the long-term prescription through community pharmacy of garments for patients with stable and uncomplicated lymphoedema.

Patients will require adequate follow-up and reassessment, particularly as the underlying medical problems may change and lymphoedema may be progressive. Opportunities for further education and training of pharmacists should be explored.

Further information


British Lymphology Society
PO Box 196
Shoreham, Sevenoaks
Kent TN13 9BF
Tel: 01959 525524
www.lymphoedema.org/bls/

Lymphoedema Support Network
St Luke’s Crypt
Sydney Street
London SW3 6NH
Tel: 020 7351 4480
www.lymphoedema.org/lsn/

References

1.     Deutsches Institut für Gütesicherung und Kennzeichnung. Medizinische Kompressionsstrümpfe RAL-GZ 387. Berlin: Beuth, 2000 (available from www.beuth.de ).
2.     Moffatt CJ, Franks PJ, Doherty DC et al. Lymphoedema: an underestimated health problem. Quarterly Journal of Medicine 2003; 96 (10): 731–738.
3.     Morgan PA, Franks PJ, Moffatt CJ. Health-related quality of life with lymphoedema: a review of the literature. International Wound Journal 2005; 2(1): 47–62.
4.     British Lymphology Society. Chronic Oedema Population and Needs. Sevenoaks, Kent: British Lymphology Society, 2001.
5.     Bates DO, Stanton AWB, Levick JR, Mortimer PS. The effect of hosiery on interstitial fluid pressure and arm volume fluctuations in breast cancer-related arm oedema. Phlebology 1995; 10: 46–50.
6.     Partsch H, Jünger M. Evidence for the use of compression hosiery in lymphoedema. In Template for practice: compression hosiery in lymphoedema. London: MEP Ltd, 2006.
7.     Badger C, Preston N, Seers K, Mortimer P. Benzopyrones for reducing and controlling lymphoedema of the limbs. The Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD003140. DOI: 10.1002/14651858.CD003140.pub2.
8.     British Lymphology Society. Consensus document on the management of cellulitis in lymphoedema. Sevenoaks, Kent: British Lymphology Society, 2006.
9.     Morgan P, Moffatt C. The National Lymphoedema Framework Project. British Journal of Community Nursing, The Lymphoedema Supplement, April 2006, S19–S22.
10.     Doherty DC, Morgan PA, Moffatt CJ. Role of hosiery in lower limb lymphoedema. In Template for practice: compression hosiery in lymphoedema. London: MEP Ltd, 2006.
 
< Prev   Next >
[ Back ]